Author Of 3 Presentations
EFFECTS OF FLUID OVERLOAD IN MECHANICALLY VENTILATED CHILDREN WITH PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME
Abstract
Background
Background: Studies in adult ARDS have shown an association between fluid overload (FO) and worse outcome. Data in pediatric acute respiratory distress syndrome (PARDS) is limited, although few studies have demonstrated worsening oxygenation and lesser ventilator free days.
Objectives
To study the effects of FO in children with PARDS
Methods
Prospective observational study between August 2017–August 2018, in a tertiary level PICU of a teaching hospital in India, including 48 children aged 31 days to 12 years, mechanically ventilated for PARDS (PALICC definition)
Results
The median(IQR) P/F ratio was 164(122,213), while oxygenation index(OI) was 7.21(4.7,13.9). Thirty five children (72.9%) had severe, 9(18.8%) had moderate and 4(8.3%) had mild PARDS. Thirty two(66.6%) children had FO% >10; more in severe than in mild-moderate ARDS (80% vs. 30.8%; P<0.001). The odds of severe ARDS increased by nearly 9 times in children with FO(OR 9; 95% CI 6.13-13.22; P<0.0001). On linear mixed modelling regression analysis, peak FO%(PFO) was a significant predictor of worst OI(F-value 23.47; P<0.001); for every 1% increase in PFO, worst OI increased by 0.67(95% CI 0.40-0.94;P<0.001).Similarly for every 1% increase in daily FO%(DFO), mean OI increased by 0.9[95% CI:0.82-0.96; P<0.001].Twenty five (83.3%) non-survivors as against 7(38.8%) survivors had FO(P= 0.002). FO was seen in 23(74.2%) out of 31 with progressive MODS, 22(73.2%) out of 30 with AKI, and 14(73.7%) out of 19 with myocardial dysfunction.
Conclusion
Fluid overload is a significant contributor to severity of ARDS; unit change in daily or peak FO% leads to significant increases in OI and mortality.
COST ANALYSIS OF PEDIATRIC INTENSIVE CARE: A LOW MIDDLE INCOME COUNTRY PERSPECTIVE
Abstract
Background
Intensive care services are expensive for both hospitals and patients.Burden of out of pocket expenditure for patients in low and middle-income countries (LMIC) is high.Cost analysis of pediatric intensive care is important for effective allocation and utilization of limited resources.
Objectives
To calculate the total and variable PICU cost incurred per patient
Methods
This prospective study was conducted in 299 PICU admissions over four, 1 monthly intervals between July 2017 to December 2018.Total cost incurred was a sum of fixed and variable costs. Former included cost of infrastructure, equipment and PICU staff salaries. Latter included drugs, disposables, laboratory tests, food, bed, travel and accommodation charges and salary loss to family.Total cost of PICU care and average out of pocket expenditure per patient were calculated. Association between cost and PRISM, ventilation and PICU stay was studied.
Results
Mean ± SD PRISM score of cohort was 22.23 ± 7.3.The median (IQR) length of PICU stay was 5(3–8) days. Average total cost incurred per patient was USD1861; of which USD1442 and 418 were fixed and variable cost respectively. Average out of pocket expenditure per patient was USD 418. Eighty % of total cost was borne by hospital and 20% by patient. The median(IQR) variable cost of a ventilated was twice that of non- ventilated child[USD 456(287–627) vs.264(150–438);p=0.0001].
Conclusion
PICU fixed costs are 3.5 times more than variable costs.Severe illness, longer ICU stay and ventilation were associated with increased costs. Intensive care in India is less expensive than developed countries.
0.9% SALINE VERSUS PLASMA-LYTE AS INITIAL FLUID IN CHILDREN WITH DIABETIC KETOACIDOSIS- A DOUBLE BLIND RANDOMIZED CONTROLLED TRIAL
Abstract
Background
Acute kidney injury (AKI) is commonly encountered during management of Diabetic Ketoacidosis (DKA). Although adult data has shown reduced incidence of hyperchloremia and AKI with Plasma-Lyte, no study has evaluated its role in pediatric DKA.
Objectives
To compare 0.9% saline with Plasma-Lyte as initial fluid in pediatric DKA with respect to incidence of new/progressive AKI, defined as a composite outcome of creatinine (defined by KDIGO), estimated creatinine clearance (defined by p-RIFLE) and NGAL levels.
Methods
Children (>1month-12 years) with DKA, were randomized to receive either Plasma-Lyte (n= 34) or 0.9% saline (n= 32) in a double blind, parallel arm, investigator initiated, randomized controlled trial. Children with cerebral edema, chronic kidney disease or who had received pre-referral fluids and/or insulin were excluded.
Results
The incidence of new/progressive AKI was similar in both [Plasma-Lyte 3(8.8%) vs. 0.9% saline 1(3.1%);unadjusted risk ratio (95% CI)-3.0(0.29,30.44);p-0.332]. The median(IQR) time to resolution of DKA in Plasma-Lyte and 0.9% saline was 14.5(12,20) hours and 16(8,20) hours respectively. Time to resolution of AKI were similar in both [Plasma-Lyte 22.1 versus 0.9% Saline18.8 hours (adjusted HR-0.22; 95% CI: 0.02-2.30;p=0.21)]. The change in pH, chloride, bicarbonate, sodium, anion gap and effective osmolality between both groups was similar. Length of hospital stay was also similar in both [Plasma-Lyte 9(8,12) versus 0.9% Saline-10(8.25,11) days;p=0.396]
Conclusion
The incidence of new/progressive AKI and resolution of AKI were similar in 0.9% Saline and Plasma-Lyte. 0.9% Saline was non-inferior to Plasma-Lyte in time to resolution of DKA, need for RRT, mortality and lengths of PICU and hospital stay.
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EFFECTS OF FLUID OVERLOAD IN MECHANICALLY VENTILATED CHILDREN WITH PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME
Abstract
Background
Background: Studies in adult ARDS have shown an association between fluid overload (FO) and worse outcome. Data in pediatric acute respiratory distress syndrome (PARDS) is limited, although few studies have demonstrated worsening oxygenation and lesser ventilator free days.
Objectives
To study the effects of FO in children with PARDS
Methods
Prospective observational study between August 2017–August 2018, in a tertiary level PICU of a teaching hospital in India, including 48 children aged 31 days to 12 years, mechanically ventilated for PARDS (PALICC definition)
Results
The median(IQR) P/F ratio was 164(122,213), while oxygenation index(OI) was 7.21(4.7,13.9). Thirty five children (72.9%) had severe, 9(18.8%) had moderate and 4(8.3%) had mild PARDS. Thirty two(66.6%) children had FO% >10; more in severe than in mild-moderate ARDS (80% vs. 30.8%; P<0.001). The odds of severe ARDS increased by nearly 9 times in children with FO(OR 9; 95% CI 6.13-13.22; P<0.0001). On linear mixed modelling regression analysis, peak FO%(PFO) was a significant predictor of worst OI(F-value 23.47; P<0.001); for every 1% increase in PFO, worst OI increased by 0.67(95% CI 0.40-0.94;P<0.001).Similarly for every 1% increase in daily FO%(DFO), mean OI increased by 0.9[95% CI:0.82-0.96; P<0.001].Twenty five (83.3%) non-survivors as against 7(38.8%) survivors had FO(P= 0.002). FO was seen in 23(74.2%) out of 31 with progressive MODS, 22(73.2%) out of 30 with AKI, and 14(73.7%) out of 19 with myocardial dysfunction.
Conclusion
Fluid overload is a significant contributor to severity of ARDS; unit change in daily or peak FO% leads to significant increases in OI and mortality.